Lifestyle behavioral weight-loss treatment for binge-eating disorder in patients with obesity: where's the harm?

Lifestyle Behavioral Weight Loss Treatment for Binge-Eating Disorder in Patients with Obesity: Where’s the Harm? - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Obesity (Silver Spring) . Author manuscript; available in PMC: 2026 Jun 1. Published in final edited form as: Obesity (Silver Spring). 2025 May 7;33(6):1058–1066. doi: 10.1002/oby.24289 Lifestyle Behavioral Weight Loss Treatment for Binge-Eating Disorder in Patients with Obesity: Where’s the Harm? Sydney Yurkow 1 , Valentina Ivezaj 1 , Carlos M Grilo 1 Author information Article notes Copyright and License information 1 Yale School of Medicine, Department of Psychiatry, New Haven, CT. USA ✉ Correspondence: should be addressed to Carlos M. Grilo, Ph.D., Yale School of Medicine, Program for Obesity Weight and Eating Research, 300 George Street (9 th floor), New Haven, CT., 06511. ( carlos.grilo@yale.edu ) Issue date 2025 Jun. PMC Copyright notice PMCID: PMC12119222  NIHMSID: NIHMS2065322  PMID: 40342236 The publisher's version of this article is available at Obesity (Silver Spring) Abstract Objective: While recent rigorous trials have demonstrated effectiveness of behaviorally-based weight loss treatment (BBWLT) for binge-eating disorder (BED) with co-existing obesity, concerns have been raised that such interventions are contraindicated because they might trigger or exacerbate eating-disorder psychopathology. This secondary analysis of a BBWLT trial examined heterogeneity of outcomes to identify the frequency individuals experienced increased symptoms. Methods: 191 participants with BED+obesity in a 6-month BBWLT trial were assessed for binge-eating, eating-disorder psychopathology, and weight at baseline, posttreatment, and 12-month follow-up after treatment (18-months post-baseline). Changes were examined at the individual level to identify cases of any increased features. Results: At posttreatment, 95.3% (N=162) of participants reported decreased binge-eating frequency and 87.6% (N=149) reported decreased eating-disorder psychopathology scores. At 12-month follow-up, 97.1% (N=135) reported decreased binge-eating frequency and 93.0% (N=120) reported decreased eating-disorder psychopathology scores. Inspection of the few instances of any increases revealed mostly small magnitudes. Conclusion: Frequency of cases with any increased symptoms of binge-eating and/or eating-disorder psychopathology was quite low at posttreatment and one year after ending BBWLT for BED+obesity. These participant-level findings add important clinical context regarding overall improvements with BBWLT for BED with obesity (large effect sizes) and challenge concerns that BBWLT exacerbates eating-disorder psychopathology. Keywords: obesity, eating disorders, behavior therapy, weight loss, binge-eating Introduction Recent evidence-base commentaries have cogently addressed the “false dichotomy” between reducing risk of eating-disorder psychopathology while also addressing patients’ concerns about excess weight ( 1 , 2 ). This issue has surfaced within increasingly heated conflict and criticisms voiced by some groups ( 3 , 4 ) that addressing concerns about excess weight in people with eating disorders (EDs) is potentially stigmatizing and harmful because it might trigger or exacerbate eating-disorder psychopathology. The recent debates, however, are not new and echo the discussions triggered by Wooley & Garner ( 5 ) and heightened concerns regarding “dieting” and eating-disorder psychopathology in the 1990s that stimulated the National Task Force on the Development and Treatment of Obesity (NTF) in 2000 ( 6 ). The authoritative NTF ( 6 ) concluded that “concerns that dieting induces EDs or other psychological dysfunction in overweight and obese adults are generally not supported by empirical studies. Such concerns should not preclude attempts to reduce caloric intake and increase physical activity to achieve modest weight loss or prevent additional weight gain.” The NTF ( 6 ) conclusions were based on the available empirical data at the time and much research with expanded assessment methods has been performed since. In their systematic review and meta-analysis of lifestyle behavioral weight control treatments in patients with overweight/obesity, Jebeile and colleagues ( 7 ), concluded that eating-disorder measures at posttreatment and follow-up were reduced , and that all of the studies that assessed binge eating also reported reduced frequencies. Importantly, Jebeile and colleagues ( 7 ) noted that four studies that specifically examined emergence of eating-disorder symptoms reported rates ranging 0% to 6.5% of patients. Such findings, while low in frequency and thus reassuring, nonetheless indicate the importance of further research to identify whether eating-disorder psychopathology might emerge in potentially vulnerable patient groups with higher weights who pursue behavioral weight loss treatments. This issue warrants research specifically in people with eating disorders at higher weight, such as those with binge-eating disorder (BED) and higher weight. BED, which is characterized by recurrent binge-eating, behavioral features reflecting loss-of-control during binge-eating episodes, distress regarding binge eating, and the absence of extreme weight compensatory behaviors ( 8 ), is associated strongly with obesity ( 9 , 10 ) and with heightened risk for psychiatric and chronic medical conditions ( 11 ). Although BED and obesity are associated strongly and co-occur frequently, they are distinct in important behavioral, psychological, and neurobiological features ( 12 , 13 ). Notably, BED is characterized by higher levels of body-image concerns (e.g., overvaluation of shape/weight) than obesity ( 13 ), which theoretically could increase vulnerability to behavioral weight loss treatments. The high co-morbidity of BED and obesity – particularly in treatment-seeking samples – suggests the importance of considering weight management in addition to the BED psychopathology. While effective psychological treatments have been developed for BED ( 14 ), in these treatments – including cognitive-behavioral therapy and interpersonal psychotherapy – little-to-no weight loss occurs. An important development since the NTF ( 6 ) report has been the growth of rigorous trials finding that behavioral weight loss treatments produce substantial reductions in binge-eating and associated psychopathology along with weight loss ( 15 , 16 , 17 , 18 , 19 ). The present study is a secondary prospective analysis of a trial evaluating BBWLTs for BED with co-existing obesity ( 17 ) with a 12-month follow-up after finishing the 6-month intervention ( 20 ). The trial evaluated two 6-month BBWLT interventions, a standard BWL and a stepped-care approach building on BWL. The stepped-care approach began with the same BWL and after one month, participants were then randomized to either weight-loss medication or to placebo and – depending on response – either continued with the BWL or switched to a guided-self-help-CBT. The two BBWLTs did not differ significantly on any primary or secondary measures at posttreatment ( 17 ) or at 12-month follow-up ( 20 ) and therefore the data were combined for the present analysis. The two BBWLTs were associated with significant reductions in binge-eating frequency (with abstinence rates of ranging 66% and 74%, respectively), eating-disorder psychopathology, and weight loss (5.1% and 5.8%, respectively) at posttreatment ( 17 ) and good maintenance through 12 months after completing/discontinuing the interventions (i.e., 18 months after baseline) ( 20 ). While these overall significant findings support the utility of BBWLT for BED, it is possible that some individuals might not benefit or even experience increased symptoms of eating-disorder psychopathology. Thus, the present study aimed to perform a detailed analysis of the heterogeneity of responses to identify whether some participants who receive BBWLT experience increases in symptoms and, if so, the frequency and severity of such events. The present study also aimed to explore potential patient and clinical predictors of any increases in symptoms after treatment. Methods Participants Participants (N=191, mean age=48.41±9.48, 71.2% female, mean BMI=38.98±5.98, 78.5% White) participated in a single-site study evaluating BBWLT for BED and obesity. The consecutively randomized patients met the following inclusion criteria: receiving a full BED diagnosis, aged 18 to 60, and BMI ≥30.0 kg/m 2 . Patients were excluded if they were already receiving evidence-based behavioral/psychological or pharmacological (e.g., phentermine, sibutramine, orlisat) treatment for eating/weight, had medical conditions that could impact eating or weight (e.g., uncontrolled diabetes, thyroid dysfunction) or represented medical contraindications (e.g., cardiovascular disease, blood pressure greater than 160/95 mmHg) or were taking other medications that could impact weight (e.g., topiramate) or represented contraindicated to potential study medication (e.g., selective serotonin reuptake inhibitors), had a diagnosis of a serious mental illness that dictated need for alternative treatment (e.g., bipolar disorder or psychotic disorder), or if they were pregnant or breastfeeding. A total of 170 (89.0%) patients attended posttreatment evaluation and 139 (72.8%) were evaluated at 12-month follow-up. Posttreatment ( 17 ) and 12-month follow-up methods and primary outcomes ( 20 ) have been previously described in detail. The study was approved by Yale Institutional Review Board. All participants provided written informed consent. Behavioral Treatment All participants received BBWLT and – depending on randomization (to standard BWL or to stepped-care) – they either continued or received additional treatments ( 17 ). BWL followed the protocol developed initially as the LEARN2000 Program for Weight Management ( 21 ) and refined thereafter for RCTs testing BWL for BED (e.g., 16,18) and obesity (e.g., 22). The weight loss intervention consists of weekly meetings with trained and monitored clinicians that lasted between 50 and 60 minutes and aimed to reinforce patients’ out-of-session reading, which encouraged gradual and sustainable lifestyle changes, rather than drastic or extreme weight control behaviors. The focus was on both food intake (i.e., improved nutrition quality, moderate decreases in caloric intake) and moderate increases in physical activity (i.e., end goal of approximately 30 minutes of physical activity 5x/week). Typical strategies build on each other, and included goal setting, logging food and physical activity, and problem-solving. Assessments The Eating Disorder Examination (EDE; 23) is a semi-structured investigator-based interview used to inform the determination of the BED diagnosis and to assess the primary and associated BED outcome variables of interest (binge-eating episode frequency in the past 28 days and eating-disorder psychopathology) at baseline, posttreatment, and 12-month follow-up. The EDE has good reliability and validity in studies with BED ( 24 , 25 ). The EDE was administered by doctoral-level psychologists who were trained and monitored throughout the course of the study to ensure inter-rater reliability and to prevent drift. In the current sample, inter-rater reliability was excellent – in 37 taped interviews, inter-rater intra-class correlation coefficients were 0.94 for EDE global eating-disorder psychopathology score and 0.86 for objective binge-eating episode frequency in the past 28 days. The EDE comprises four subscales (restraint, eating concern, shape concern, and weight concern) and those are combined to generate a total Global score reflecting overall eating-disorder psychopathology. The EDE global score was considered the primary measure of eating-disorder psychopathology as recent psychometric work has indicated it has good internal consistency ( 25 ). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P, 26) was administered at baseline to confirm the BED diagnosis and to inform the baseline characterization of lifetime and current psychiatric disorders, including exclusionary criteria. Statistical Analyses Group differences were explored in a series of paired-sample t-test. Descriptive statistics were used to explore individual changes on binge-eating frequency, eating-disorder psychopathology (EDE Global score and subscale scores), and weight outcomes. Differences in those who experienced any increase in symptoms compared to those who did not were explored in a series of ANOVAs and chi-square tests. Results Overall Changes in Binge-Eating Frequency and Eating-Disorder Psychopathology Figure 1 summarizes overall participants’ changes for binge-eating frequency and eating-disorder psychopathology. Binge-eating frequency (during the past month) decreased from baseline (19.67±14.85) to posttreatment (2.44±7.24, t (169)=14.75, p <.001, Cohen’s d =1.13) and from baseline (19.37±13.73) to 12-month follow-up (2.34±4.61, t (138)=14.35, p <.001, Cohen’s d = 1.22). Global scores on the EDE also decreased from baseline (2.64±.87) to posttreatment (1.77±.87, t (169)=14.00, p <.001, Cohen’s d =1.07) and from baseline (2.64±.85) to 12-month follow-up (1.65±.88, t (138)=13.80, p <.001, Cohen’s d =1.17) Figure 1. Open in a new tab Frequency of binge-eating episode frequency in the past 28 days and EDE Global scores for participants at baseline, posttreatment, and 12-month follow-up Note . post = posttreatment, 12m = 12-month follow-up Individual Changes in Binge-Eating Frequency and Eating-Disorder Psychopathology Figure 2 and Figure 3 summarizes specific participants’ changes from baseline at posttreatment and 12-month follow-up. In total, seven (4.1%) participants reported binge-eating frequency increases (during past month) at posttreatment (increases ranging from 1 to 15 episodes). Of the remaining participants, 163 (95.9%) reported decreased binge-eating frequency. At 12-month follow-up, three (2.2%) participants reported increased binge-eating frequency from baseline (ranging from 3 to 16), and 135 (97.8%) reported decreased frequency. Figure 2. Open in a new tab Individual changes on binge-eating episode frequency in the past 28 days from baseline to post-assessment and 12-month follow-up Figure 3. Open in a new tab Individual changes on EDE global scores from baseline to post-assessment and 12-month follow-up At posttreatment, 21 (12.4%) patients reported increases in EDE global scores, with (ranging from .01 to 1.21); the remaining 149 (87.6%) patients reported decreased scores. At 12-month follow-up, 19 (13.7%) patients reported increased EDE global scores from baseline (ranging from .01 to 1.13); the remaining 120 (86.3%) participants reported decreased EDE global scores. We explored EDE subscale score changes in the 21 (12.4%) participants who increased on the EDE global score to provide descriptive clinical context for the increased global scores. Of the 21 participants who had increased EDE global scores at posttreatment, 17 increased on the restraint subscale (with 2 scoring above the clinical cut-point of 4), 5 increased on the eating concern subscale (with 1 scoring above the clinical cut-point of 4), 8 increased on the shape concern subscale (with 5 scoring above the clinical cut-point of 4), and 10 increased on the weight concern subscale (with 3 scoring above the clinical cut-point of 4. At 12-month follow-up, in the 19 (13.7%) who had increased Global EDE scores from baseline, 14 increased on restraint subscale (with 3 scoring above the clinical cut-point of 4), 8 increased on eating concern subscale, (with 1 scoring above the clinical cut-point of 4), 8 increased on shape concern subscale (with 5 scoring above the clinical cut-point of 4), and 9 increased on weight concern subscale (with 4 scoring above the clinical cut-point of 4). Regarding meeting the threshold for clinical cutoff on the EDE Global score (≥4), 9.9% of patients (N=19) met the cutoff at treatment baseline whereas only two patients met the clinical threshold at posttreatment and/or 12-month follow-up. At baseline, one patient who was just below the cutoff (3.93), was above the cutoff at posttreatment (4.94) and again at 12-month follow-up (4.86). One additional patient, who had improved from their baseline score, met the clinical cutoff at 12-month follow-up (baseline = 4.37, posttreatment = 3.64, 12-month follow-up = 4.20). No other patients met the EDE clinical cutoff at posttreatment or 12-month follow-up. Weight Outcomes Figure 4 includes overall weight outcomes. Overall, compared to baseline (38.79±5.66) participants’ mean BMI was lower at posttreatment (36.61±5.87, t (162)=10.36, p <.001, Cohen’s d =.81), and compared to baseline (38.38±5.88); participants’ mean BMI was also lower at 12-month follow-up (37.04±6.25, t (142)=5.79, p <.001, Cohen’s d = .48). Figure 5 includes individual weight outcomes. At posttreatment, 77.9% (N=127) lost weight, and 22.1% (N=36) gained. Compared to baseline, 18 months later (at 12-month follow-up after treatments), 66.4% of patients (N=95) had lost weight. Figure 4. Open in a new tab Body mass index at baseline, posttreatment, and 12-month follow-up Note . BMI=body mass index, post=posttreatment, post = posttreatment, 12m= 12-month follow-up Figure 5. Open in a new tab Individual percent weight change at posttreatment and 12-month follow-up Sociodemographic and Clinical Predictors of Missing Data Since our examination of instances of symptom worsening relied on available data at posttreatment and 12-month follow-up, we explored whether missing data were predicted by participants’ sociodemographic and baseline clinical severity variables. Analyses revealed that age, gender, and race were not associated significantly with missing data. Baseline eating-disorder psychopathology data, binge-eating frequency, BED age of onset, and BMI were not associated significantly with missing data at either posttreatment or 12-month follow-up assessments. Weight change at posttreatment and weight change at 12-month follow-up were not related to missingness/completion of the respective timepoints (all p s > .05). EDE global score was not associated significantly with missing data at 12-month follow-up (2.85±.98 vs 2.64±.85; F (1,189)=2.24; p =14; η p 2 =.01) but was associated significantly with missingness at posttreatment, albeit with a small effect size (3.11±.84 vs 2.64±.89; F (1,189)=5.41; p =02; η p 2 =.03). Individuals with lifetime other ED diagnosis (other than BED, i.e., anorexia nervosa or bulimia nervosa) were not less likely to attend the posttreatment and 12-month follow-up compared to those without a lifetime diagnosis. At posttreatment, one (7.1%) participant with a lifetime other ED diagnosis did not complete their assessment (compared to N =20 (11.3%) of those who do not have a lifetime other ED diagnosis; Fisher’s exact test p = 1.00). At 12-month follow-up, two (14.3%) participants with a lifetime other ED diagnosis did not attend their assessment (compared to N =50 (28.2%) of those who do not have lifetime other ED diagnosis, Fisher’s exact test p = .36). Current comorbid psychiatric disorder (major depressive disorder, anxiety disorder, mood disorder, substance use disorder) was not associated with attending posttreatment or 12-month follow-up assessment. At posttreatment, 12 (16.0%) patients with current psychiatric comorbidity did not attend their assessment, compared to 9 (7.8%) of patients who did not have psychiatric comorbidity ( p = .08). Similarly, at 12-month follow-up no difference was observed, with 19 (25.3%) participants with current psychiatric comorbidity not attending and 33 (28.4%) without psychiatric comorbidity who did not attend ( p = .64). Demographic and clinical differences in those with symptom increases Race and age were unrelated to improved versus increased EDE Global scores at both posttreatment and 12-month follow-up (both p s > .22). At posttreatment, sex was unrelated to improved versus increased EDE Global ( p =.97) but at 12-month follow-up, men were more likely to report increased EDE global scores (χ 2 (1) = 11.99; p < .001; Φ = −.29). A lifetime history of an ED other than BED (AN or BN) was unrelated to increased EDE Global scores at posttreatment and at 12-month follow-up (both Fisher’s exact test p s > .06). The presence or absence of current psychiatric comorbidity (major depressive disorder, anxiety disorder, mood disorder, substance use disorder) was also unrelated to increase/decrease in EDE Global scores at posttreatment and 12-month follow-up (both p s > .09). Similarly, a lifetime diagnosis of AN and/or BN was unrelated to an increase in binge-eating frequency at posttreatment and 12-month follow-up (Fisher’s exact test both p s = 1.00), and current psychiatric comorbidity was unrelated to an increase in binge-eating frequency (Fisher’s exact test both p s = 1.00). Discussion To our knowledge, this is the first study to assess the frequency of increased symptoms of binge-eating and eating-disorder psychopathology at the specific participant level in those with BED with obesity treated with BBWLT. In this secondary analysis of a RCT testing BBWLT for BED with obesity ( 17 , 20 ), we found that individual cases of any increased binge-eating frequency or eating-disorder psychopathology were infrequent. In terms of binge-eating, during the course of the 6-month treatment, 4.1% of participants reported increases, and 2.1% reported increases during the 12-month follow-up after having completed/discontinued treatments. Somewhat more frequent were individual reports of any worsening of associated eating-disorder psychopathology (12.4% at posttreatment, 13.7% at 12-month follow-up). Overall, these frequencies are somewhat re-assuring, particularly when viewed within the context of the high chronicity that characterizes BED ( 10 ), and especially because the observed increases were generally quite small (e.g., one patient’s global EDE score increased from 3.76 at baseline to 3.78 at posttreatment). Further, the overall magnitude of the increases was small, and below the threshold for clinical cutoff. Moreover, only two patients scored above the clinical cutoff at posttreatment and/or 12-month follow-up. Of those two patients, one was just below the clinical cutoff at baseline (3.93) and increased by 1.01 (at posttreatment) and 0.93 (at 12-month follow-up compared to baseline) and the second patient above the clinical EDE clinical cutoff at 12-month follow-up actually decreased in their baseline score by 0.17. A recent systematic review and meta-analysis concluded that while BBWLTs can produce weight loss in individuals with BED, those with co-occurring BED and obesity lose less weight than those with obesity without BED ( 27 ). With that context regarding the challenge of attaining weight loss in those with BED with co-existing obesity, we note that sustaining weight loss over time is difficult. Given this, our primary analyses regarding good overall weight-loss maintenance after BBWLT for BED ( 20 ) were extended in this secondary analysis here at the individual level which revealed that weight loss was attained by the majority at posttreatment (77.9% [N=127]) and sustained through 12 months after finishing treatments (66.4% [N=95]). More broadly, these findings should be considered within the context of findings that many patients with BED with co-existing obesity report having experienced substantial weight gains in the year prior to seeking treatments ( 28 ). While an additional goal of this secondary analysis was to explore predictors of cases with increased symptoms, this proved difficult because of the very low observed frequencies of increased symptoms. Within the context of limited power, our exploratory analysis revealed that most sociodemographic variables were unrelated to clinical worsening. One isolated finding was that men were more likely to report worsening on eating-disorder psychopathology at 12-month follow-up. Of the 41 total men who were assessed, 12 (8.6% of full sample) reported worsening, compared to the 98 women who were assessed with 7 (5.0%) reporting worsening. Our exploratory analyses also revealed that baseline clinical variables reflecting severity were unrelated to clinical worsening. Importantly, analyses revealed that a history of other lifetime eating disorders (anorexia nervosa and/or bulimia nervosa) and current other psychiatric comorbidity were unrelated to clinical worsening. These findings challenge views that eating-disorder psychopathology might emerge during BBWLT in potentially vulnerable patients with BED with higher weights (i.e., those who have histories of anorexia nervosa or bulimia nervosa or with current psychiatric comorbidity) who pursue behavioral weight loss treatments. These findings add important clinical context regarding overall effectiveness findings of BBWLT for BED with obesity. Specifically, the findings suggest that increased symptoms of binge eating and eating-disorder psychopathology are infrequent and moreover, in most of the (few) individual cases with any increases, the magnitude of most increases was small. Importantly, these findings converge with recent research of patients’ perspectives. In a recent qualitative study, participants with BED who engaged in a BBWLT treatment study were asked their perspectives ( 29 ). Overall, four main themes emerged from the in-depth interviews capturing patients’ perspectives: BBWLT did not perpetuate weight-based stigma, BBWLT is useful in managing health concerns, calorie and weight goals do not negatively impact BED, and individuals should have the freedom to choose an intervention that aligns with their goals ( 29 ). We note potential limitations to consider as context for our findings. Although our study did not have a control group (i.e., without BBWLT), this potential limitation ends up being moot given the observed low frequency of symptom increases which we defined as “any” increases and that most of the rare increases were of a small magnitude. Nonetheless, future work examining positive and negative outcomes of BBWLT for BED may benefit from comparison conditions for context. An important potential limitation to the current study is patient dropout. In a recent review, Forman and colleagues ( 27 ) noted that, compared to individuals with obesity alone, those with BED are more likely to drop out of BBWLT. In the present study, retention was generally good: of the 191 participants who started the study, 170 (89.0%) attended the posttreatment assessment and 139 (72.8%) attended the 12-month follow-up. Our analyses revealed that baseline sociodemographic and most clinical severity variables were not related to completion of assessments (with one exception that participants who did not complete posttreatment assessments had higher global EDE scores at baseline than those who did not; this difference, however, reflected a small effect-size (η p 2 = 0.3) and was no longer observed for missing data at 12-month follow-up). With this limitation in mind, we note the following considerations. First, the frequency of noncompletion was low, and even if all participants with missing data had experienced symptom increases after treatment, the take-home finding would still be that the large majority of participants improved with BBWLT (with overall outcomes reflecting large effect sizes). Even with that assumption (i.e., all missing data reflected increased symptoms), 78% of participants would have been classified as improved at posttreatment. Second, it is well-known that studies of treatment-seeking and utilization actually indicate the converse – i.e., that greater severity is associated with greater treatment utilization ( 30 ). Additional limitations include the single-site study staffed by highly trained and monitored clinicians. Thus, it is uncertain whether these findings generalize to different clinical settings or health care providers with different training or expertise. Because increases in binge-eating frequency and eating-disorder psychopathology were infrequent, we had limited power to detect predictors of who had increased symptoms. Additionally, we had a limited number of male participants, and the one isolated finding that men were more likely to report increased symptoms requires replication in future studies. Finally, we note that our follow-up was limited to 12-months after completing the 6-month BBWLTs (i.e., 18-months after baseline). Thus, it is possible that with longer-term follow-up additional cases with symptom increases might be observable. At the 12-month follow-up, our binge-eating remission rate was approximately 41%–45%. For context, Wilson and colleagues ( 19 ) reported a 50% remission rate for BWL at 12-month follow-up and 47% at 24-month follow-up, suggesting good maintenance of overall group benefits through 24-months after finishing treatments. It is possible that even with the context of such good overall benefits through 24 months that there could be additional instances of increased symptoms, although that was not examined by Wilson et al ( 19 ). Conversely, the overall benefits of BWL reported here through 12-month follow-up and through 24-month follow-up ( 19 ) need to be considered with the broader clinical reality that BED is a chronic disorder; indeed the 12-month persistence of BED in a national sample of US adults was calculated at 63.5% ( 10 ). Moreover, given the chronicity and complexity of BED, Occam’s razor would suggest that instances of increased ED symptoms so long after completing BBWLT might not be “caused” by the BBWLT. In sum, we found that participants with BED with obesity treated with BBWLT infrequently experienced any increases in binge eating or eating-disorder psychopathology. These findings add important clinical context regarding overall effectiveness findings (large effect sizes) of BBWLT for BED and co-occurring obesity ( 17 , 20 ) and challenge concerns that BBWLT exacerbates eating-disorder psychopathology in patients with both BED and obesity. Study Importance. What is already known about this subject? Recent trials have demonstrated the overall effectiveness of behaviorally-based weight loss treatments (BBWLT) for binge-eating disorder (BED) with co-existing obesity. Concerns have been raised that such interventions are contraindicated because they might trigger or exacerbate eating-disorder psychopathology. What are the new findings in your manuscript? In BBWLT, the frequency of increases in binge eating or eating-disorder psychopathology was rare, and when it occurred it was often of small magnitude The large majority of patients receiving BBWLT had decreases in both binge eating and eating-disorder psychopathology (reflecting large effect sizes) at posttreatment and 12-month follow-up (18 months after baseline) How might your results change the direction of research or the focus of clinical practice? These findings challenge concerns that BBWLT might induce or exacerbate eating-disorder psychopathology in patients with BED and obesity BBWLT appears to be a viable intervention for patients with BED and co-existing obesity who desire decreases in both eating-disorder symptoms and weight loss Funding: This research was supported by National Institutes of Health (NIH) grant R01 DK49587 (Dr. Grilo). The authors were also supported, in part, by NIH grants R01 DK114075 and R01 DK112771. Funding agency played no role in the content of this paper. Footnotes Potential Conflicts of interest: The authors declare no conflicts of interest. Dr. Grilo reports broader interests, which did not influence this research, including royalties from Guilford Press and Taylor & Francis Publishers for academic books. Data Sharing: De-identified data will be provided in response to reasonable written request to achieve goals in an approved written proposal (from non-commercial academic researchers). References 1. Cardel MI, Newsome FA, Pearl RL, et al. Patient-centered care for obesity: how health care providers can treat obesity while actively addressing weight stigma and eating disorder risk. J Acad Nutr Diet. 2022;122(6):1089–1098. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Cardel MI, Newsome FA, Pearl RL, et al. Authors’ response. J Acad Nutr Diet. 2023;123(3):400–403. [ DOI ] [ PubMed ] [ Google Scholar ] 3. Steinberg DM, Bohon C. 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